| NPI | 1073074365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0008X Dentist, Oral and Maxillofacial Radiology (Licence: PA DS041592) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041592) |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2019-03-28 |